Referral

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Referral form

This form is for professionals and parents making referrals and requesting quotes.

Person completing this form

Your name Your email address Your phone number Your relationship to the child

This is a referral for the Ministry of Education Counsellors in Schools service.

For referrals to the Counsellors in Schools service please provide the child's National Student Number

I have an approved plan and will be using Flexible Funding.

I confirm the child and/or their parent/caregiver is aware of this referral to reThink Children's Therapy and the specific documents being shared. I have informed them that this information is for assessment and that they have the right to access and correct their information held by reThink.

If you are not the parent or caregiver

Parent/caregiver's name Parent/caregiver's address Parent/caregiver's email address Parent/caregiver's phone number

Child

Child's name Child's date of birth Child's ethnicity
Māori
Pacific Heritage
NZ European / Pākehā
Asian
Middle Eastern
Latin American
African
Other

Child's address School Year level Classroom teacher Other professionals involved

Additional information

Please include what you are seeking from reThink and why

How did you hear about us?

PHONE: 022 100 1440
EMAIL: office@rethink.net.nz
ADDRESS: 144 Rattray Street, Dunedin

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